Burnout: the new normal

Burnout: the new normal

 

John is an ER doctor with over 20 years of experience.  He may be a little gruff, but his colleagues love him.  He is always available to help, even when he is exhausted – which is most of the time.  John may not always have the best bedside manner, but everyone knows they can count on him to do the right thing.  In conversation, John frequently seems to be lamenting the fact that patients are so entitled these days or predicting the collapse of healthcare in general.  But that’s just John.  He’s always been that way.

Is John burned out?

Previously, I might have said no.  My perception of burnout was that once you reached it you were done.  Not functional.  Kaput.

Actually, professional burnout is not like that at all.  You can be functional and burned out  . . . it happens all the time.

In fact, there is an epidemic of physician burnout happening right now.  In Canada about half of all physicians report significant symptoms of burnout.  The numbers are similar in the US.  The specialty with the highest rate of burn out?  Emergency medicine.  Over two thirds of ER docs like me are burned out.  Family doctors are close behind.

Think about that for a second.  Chances are that your own family doctor is burned out.  Even better that the next ER doc you see is struggling to do her job due to burnout.

And rates are increasing.

But this is not about me.  It’s not even just about doctors.  This phenomenon of burnout is rampant in healthcare at large.

Does it matter?

I used to think that exhaustion, compassion fatigue, and occasional hopelessness were just part of the job.  We are paid reasonably well with good job security and are generally respected members of society.  Maybe feeling worn down, bitter, and jaded is the price of admission.  Normal.  Functional burnout.

Unfortunately, even though “functional burnout” is now the rule rather than the exception, it has been directly linked with some very undesirable outcomes:

  • Lower quality of care
  • Higher malpractice risk
  • Higher staff turnover
  • Higher rates of substance abuse
  • Physician suicide (3x higher than national average)

Accepting functional burnout as the new normal in medicine is unacceptable.  Not just because it is hard on the people who work in healthcare, but because it affects everyone.

But what is burnout?  I sometimes feel that the term is thrown around a little too loosely and it is not a term to be taken lightly.

Real professional burnout has three components: exhaustion, apathy, and self-doubt.

“I’m not sure how much longer I can keep doing this.”  This is a sign of exhaustion.  If you are asking yourself this question on a regular basis, chances are your physical and emotional gas tanks are running on fumes.

“I’m finding it hard to care anymore.”  This is apathy.  If you find yourself frequently needing to vent about your job, feeling cynical, noticing that you can’t connect with patients the way you used to, chances are you are suffering a deficit in our most essential resource: compassion.

“Am I really making a difference?”  Self-doubt is a tricky one.  If you find yourself doubting the importance of your work and the quality of your care, beware.  This is a late sign of burnout.  (Interestingly, research shows that many male physicians don’t experience self-doubt no matter how burned out they are.)

Looking at the evidence, burnout is an enormous problem in healthcare – in Canada, the US, and overseas.  I’m not quite like John, but I am definitely noticing exhaustion and compassion fatigue way too often in myself and my colleagues.  How did this happen?

I wish there was an easy answer, one big problem we could target and solve.  But as with most issues of mental health there are a handful of factors that come into play.

If your workload is too much, too complex, or too urgent eventually you will become overwhelmed.  Medicine scores 3 for 3.  International research shows that Canada has far fewer physicians per capita that most other OECD countries, with a much higher workload per doctor.  Combined with longer wait times which increase the urgency of management and the picture is not pretty.

The combination of immense responsibility and limited control are a proven recipe for burnout. The human body is a complicated machine.  Sometimes it will break down no matter what we do.  Contrary to popular opinion, physicians influence the course of illness.   We do not control it.  And, yes, sometimes we make mistakes.  Physicians are acutely aware of the incredible burden of responsibility we carry.  When things go badly, patients and families look first to the physician – whether it be for comfort, explanation, or blame.

Sometimes physicians are treated unfairly by patients, but injustice can come from other places.  If there is a lack of transparency in decision making, or just plain honesty about the state of things, it is impossible to feel like a valued member of the team.  More likely you will feel resentful or simply checked out.  The Ontario government’s actions over the last 10 years is a case study in what not to do if supporting frontline workers is the goal.

Speaking of government factors, I shudder every time I hear a politician advertise that our healthcare system provides “excellent care” – ugh.  Physicians want to provide excellent care but the truth is that we do not have the resources to deliver on that ideal.  Wait times in the ER are measured in hours – sometimes 4 or 5.  Admitted patients might spend days in a hallway. You might spend months waiting for a specialist appointment.  It is difficult to reconcile our values with the reality of healthcare in Canada.

The healthcare system used to be run by physicians and nurses with frontline experience.  Now it is run by administrators.  It should be shocking that Canada has ten times the number of health care bureaucrats per capita as Germany (in spite of ranking worse on most quality measures).  Communication between policy makers and frontline workers has never been worse.

The sad irony is that just as we need physicians to be more involved in health policy decisions, burned-out doctors are very unlikely to get involved.  They just don’t have enough gas in the tank.

It really has become the norm to be functionally burned-out in medicine.  In fact, it’s ingrained and normalized from day one in our training.  But research shows it is getting worse, and I fear we are reaching a tipping point.  Physicians are suffering.  Patients are suffering just as much, if not more.

“The gap between knowing and doing is larger than the gap between ignorance and knowledge.”  – Dr. Robert Sutton

It is not enough to know about this. We have to take action.

I commend all the physicians who are talking about this.  There has been a proliferation of MD blogs and articles of late discussing how unsustainable this system is.  Sometimes these brave physicians are attacked for their honesty by non-physicians who can’t understand how a doctor who earns a good stable income could feel this way.  All I have to say is that we are human.  And it’s not about the money.  It’s about life and family and contribution to community and wanting all of those things to be okay for the long haul.

As you may know from my last post, part of the reason I am writing this blog is because I am questioning my own assumptions.  I am no longer certain about the longevity of a career in clinical medicine.   Perhaps there are non-clinical roles I could pursue.  Part of me feels guilty at the prospect of no longer caring for patients directly in this broken system.  Part of me feels it is inevitable.

In the meantime, whether you are a physician, nurse, teacher, lawyer, business owner or caregiver, if you have identified symptoms of burnout in yourself please take action.  There will be many things we cannot control – which, of course, is a big part of the problem – but we have to make the decision to take better care of ourselves.  If we don’t, we’re no good to anybody.

And if you are noticing signs of burnout in a colleague, talk to them about it.  Share your own story.  This is more common than anyone is admitting.

 

 

 

 

 

10 Replies to “Burnout: the new normal”

  1. As someone who burned out both badly and permanently, I can not only relate, but can also speak to what I think are some of the root causes of the problem, and why it might be so increasingly pervasive in medicine.

    You correctly point out the external pressures acting on MDs: increased time pressures; increased bureaucratic demands; increasing restrictions on professional independence; and increasing complexity of care in the setting of cutbacks, not only to doctors themselves but also system-wide.

    At the risk of heresy, I honestly think the problem is with clinical medicine itself. Especially in the generalist fields, we’ve moved away from the diagnose-and-treat-to-cure origins of the profession, and on to something that is significantly more mundane, and way more frustrating thanks to mismanagement (I can only imagine what % of an ER doc’s day is spent horse-trading over beds).

    The modern job is also very much divorced from what’s expected of the prospective doctor wanting to get in the door. You do not need to be an A+ student with research on your CV to be a good doctor.

    Doctors that burn out are, in some ways, uniquely screwed as compared with other careers. The dude with the MBA from your previous post can always change jobs, even fields, or do independent consulting if he hates his job. No doctor can up and change fields anymore on a whim. An ER doc can switch to general practice with enough ease (at least outside Ontario), but there are only a handful of things a dissatisfied MD can do without a return to residency. For a lot of docs, it’s simply not reasonable or feasible, especially if they don’t live in or around a big city.

    The other thing with docs is that once you’re burned out from patient care it leaves scars that don’t readily heal. Medicine will always entail intense personal contact with many people, some of whom suffer traumas and tragedies that leave indelible marks on your psyche/soul. You can only take so much before you’re in the catch-22 of not being willing to let yourself “take it home with you”, but not being able to function as a doctor by creating the requisite distance. It does happen in other professions – criminal law comes to mind in cases of sexual assault/abuse – but medicine sees it more than most.

    I’d welcome you to contact me personally or check out my own website where I blog about this stuff as well as medical politics. Cheers

    1. There is much to learn about this process of “burnout” – I appreciate your contribution of some very salient and insightful comments, Franklin. After perusing your blog it is clear that you are further down this path than I am. Thanks for allowing us to learn from your painful experience.

  2. Thanks for writing this and the great comment above. I decided to leave family medicine after 33 years. I have at least another 10 years in me, God willing, but I am doing something different now as I need my soul to be at peace. What started to really eat into my peace of mind, was that everyone seemed to know what we should be doing and how we should do it. They made no attempt at disguising their unwelcome meddling. The patient would come in with three complaints – I would love to listen to the patient and pay attention to the details of those complaints – however, I was also expected to do a quick review of medications, update the history, review preventative care and the last blood work that was done in ER. ( often that would be somewhere else, not in the EMR and not on my desk….so it had to be looked for, as the patient was told to see me in three days to discuss it. Medical records just could not always keep up with sending things our way. ) So patient would be upset with our office etc etc. We all know the story. Throw in that patient would often need me to decode the last specialist visit ( they did not want to ask questions at the time of that appointment as the specialist seemed to be in a hurry) All this in a 15 minute appointment. And booking another appointment was not always an option because, as you can guess, time is a scarce commodity in rural practice. Most of us would have loved to spend all the time that the patient needed, but others were waiting and there were many banging on the doors, waiting to get a precious appointment. Hospital work ( which I truly loved) became more complicated with time. Doing rounds in the morning became quite onerous and beds were never enough. Fighting, literally, for the lives of our patients by trying to get them transferred to a centre with specialists ( there were only GPs at the time, very seldom supported by in-facility specialists), became an everyday nightmare. This was usually followed by 10 phone calls during the day for various needs that arose after rounds. Nursing Homes became less efficient because of constant staff changes, resulting in numerous calls to the office every day and even after we just completed rounds. They were understaffed and underfunded. They still are. Then the 2-3 hours of administrative work every single day – it had to be done. You finish your hospital work, your clinic day and then stay seated to do the admin ( on an empty stomach). We wasted hours daily on doing things that we were told to do by the various administrative organizations (colleges, ministry etc). It was never enough. Everyone just kept asking, demanding, wanting more. Until I had nothing left to give. I love talking to, treating, examining and being with my patients. At the end, I had to leave them to save my dried up, exhausted soul, because the ‘other’ demands became too much and robbed medicine of the art and the joy of being a family doctor. Many of my colleagues still feel the same. The doctors that work until they are in their 80’s come from another era – they are riding the beginner wave of this new era – they started practising medicine when it was still an art and most people still felt satisfied just to see a doctor. Now we have to lay out designer medicine and for what? Designer medicine until the patient decides his/her doctor has to pull the plug because they said so and that’s that. All the while the cost of that designer medicine ( which everyone feel they are entitled to because health care is free and they pay their taxes ) is going through the roof and it is apparently our fault. But in the meantime, we were bombarded with things we should do, check on, talk to the patient about and never ever offend them by, heaven forbid, laying our professional opinion before them and trying to guide them away from fruitless, hazardous treatments. On the one hand we were encouraged to be comprehensive. On the other hand, we were told we were the gatekeepers and should contain cost. Balancing patient needs/demands against expense, while bearing in mind the “ought to’s” handed down to GPs by all the other specialties and colleges, is a terrible job. It is rich ground for constant inner turmoil. The final straw came when I read an article in the CPSO journal, where a writer was talking about smoking cessation and how that should be a priority at every visit that every GP should and could aspire to. Her comment: “ It only takes a minute and there is no excuse”, had me hopping mad. It does not take a minute. We all know that. And, yes, we do it anyway. But the rather arrogant manner in which it was laid out really got to me. It was then I realized, I had had enough. No one should feel that upset by such an inflated opinion. Medicine should be handed back to doctors. We need transparency and honesty from the Pharmaceutical Companies, we need transparency from those who put together our guidelines, we need transparency from those who demand things from us. The politicians need to get out of the mix. They are deadly. Most of all, the patients need to become the focus again. I thought it was asking for an impossibility. So, it was time to recognize my situation for what it was: burnout. It took me 10 months to start feeling like a normal human being again. I am almost there. It was worth it.

    1. That was beautiful Celeste! Can I copy your letter and hand it to my patients when I quit/ retire? After 28 yrs of rural family medicine I definitely feel burned out. What does a normal human being even feel like?

    2. Thank you, Celeste. You have a great ability to communicate the pain and turmoil of burnout in a way that I haven`t (yet). I hope that lay people and maybe even a politician or two happens on my little blog so they can read stories like yours. Glad to hear you are starting to feel “like a normal human being again.”

    3. Hi Celeste

      I am saddened to hear of your experience. I am a General Internist working both suburban and rural. I have been in practice for less than 20 years, yet I have already experienced many of the same frustrations that you (and many others) are going through. It is reassuring to hear that you did finally start “feeling like a normal human being again.” I am not even sure what that might feel like – as is true for most if not all of us, I have worked towards this career since I was young, to the exclusion of many normal human activities.

      There is no doubt that the CPSO doesn’t help the situation. They take the fees in the guise of regulating and protecting us. Instead, there seems to be a drive to demonize the physicians, and demonstrate inadequacies. I have colleagues in various specialties who were told that their “Peer Review” was deemed unacceptable because they didn’t do a family history at least three generations deep, or because they didn’t note down a list of all the medications the patient had been on since they were born. Or that their charts didn’t have a formal list of all the ongoing medical issues (despite each note containing the relevant data.) On the other hand, I have been told that due to privacy rules, I should not be marking down the racial background of the patient, even though it may be an element of their risk profile, or may impact the probability of certain illnesses.

      The actions of the Ministry of Health essentially are telling physicians that they aren’t worth as much as they were in years prior. I like to think that my value has at least remained stable, if not increased, over the last few years. Apparently, that isn’t the case, though I sometimes wonder what data was used to make that determination. On the other hand, the rapidly increasing number of administrators have enjoyed protected incomes with raises, as well as very generous pensions and benefits, all without evidence of beneficial impact on outcomes.

      The administrative burden has increased exponentially. Insurance companies require notes more frequently, and don’t pay (and I can’t, in good conscience, really ask a patient on social assistance to pay $100 or whatever for my comprehensive chart review). Patients have become more complex, and more demanding. Patients often arrive armed with a litany of google searches which then become my job to decode and decipher. Hospitals now require us to use voice dictation. So instead of three minutes dictating a comprehensive note, I am now required to spend 15 minutes dictating, then editing a letter. And then I am criticized for not being able to get to the next patient in a timely manner. But of course, this has saved the hospital $5 so my time is not relevant. In essence, the admin has told us that the next patient isn’t relevant either.

      There is a growing body of data that shows that EMRs don’t actually improve the patient interaction (though they may improve some outcomes). Physicians using EMRs have less eye contact with patient, thus are less connected with the patient. I can only wonder how much information is missed because of this little change. There is no doubt that EMRs have resulted in increased stress for physicians. In my practice, I have had patients comment that they appreciate that I don’t type/create the encounter note in front of them, but instead take quick handwritten notes. They feel like I’m paying more attention to them, instead of the screen. But of course, the CPSO tells us that this is an antiquated approach. And this approach means that I have to spend extra time at the end of the day generating the formal notes.

      In essence, the regulators are telling us how to practice, and it doesn’t align with the reasons that we became physicians to begin with. It’s all about efficiency and data. But what about actual patient care?

      And what about the sacrifices of our families? The Ministry has basically said that we don’t work hard (enough). Conversely, my wife has said that I am married to medicine first, and then her. My children have suffered because I couldn’t be there for hockey games, soccer games, piano recitals, swimming lessons, and school events. And my parents complain because I can’t even find time to stop in to see them, even though they live only 20 min away. Yet all of them have accepted it because it is the price of having a physician in the family. This is a cost that can’t be measured. And in many cases, it can’t be recovered.

      Am I angry? Yes. Because I can’t take care of the patients in the way that I would like to.

      Am I frustrated? Yes. Because I have to spend more time connecting with papers and computers than with my patients and colleagues. And because I have to spend as much time justifying what I have done as actually doing.

      Am I burnt out? According to every scale and measure, yes. If only I had time and insurance coverage to establish just how far gone I am. If only someone cared for me the way I am expected to care for others. If only the government actually prioritized both health care and “Health Care Provider Care.”

      Or maybe if we were at least compensated and provided benefits in the same fashion as the Minister himself.

      But after 12 years of post-graduate education, and almost 20 years of practice, I have to continue. What else am I qualified to do? And who will pay the remainder of my practice debts, and then fund my retirement (and pay for my kids school, and pay for health care costs, etc etc)?

      In the end, the most telling feature is how many physicians would guide their children to go into medicine. From my (non-scientific) survey, the numbers are decreasing – rapidly.

  3. Wow. Amazing post and comments. Thank you. I am privileged to read your stories. More awareness on demands and burnout needs to be taught early on. And those demands mitigated everyday..

  4. Regarding burnout. It is not just doctors and nurses who are suffing it, but the very system is too.
    As many before me have opined, the problems in today’s medical world are systemic. Government likes to claim it is the answer to our problems, but it is in fact the problem that must be answered.
    Government, like all bureaucratic entities (and this most certainly includes our professional organisations) acts like a living creature. It seeks first to survive, second to feed and third to reproduce.
    All reproducing systems are subject to evolutionary forces. Government has evolved into the overly complex monstrosity we see because like all other replicating systems it will adapt to fit its environment. That environment is a popularity contest pseudo-democracy where the party that promises the most “free” stuff gets voted in. Regardless of what the talking heads may say publically, government has only two problems it really wants to solve: Get elected, and then get re-elected. Every other problem is a resource for government to draw upon as it grows.

    It is not just medical administration that has this issue. Just look at the crime and victim industry that goes by the misnomer of “Justice System” in Canada. Repeatedly releasing career violent offenders and drunk drivers, many of whom have over 50 convictions for crimes that caused irreparable harm to their victims, all the while shackling the police so they cannot provide adequate protection and steadfastly refusing to promote multilayered, proactive, timely and effective personal defence guarantees an ongoing flood of victims for the system and the so-called victims’ rights groups to feed on.

    Being a living entity, a society and its government will undergo a natural life cycle. There is a birth, a childlike growth phase, an adult consolidation phase, a senescence and eventually a death. By all measures, the western world is in advanced senescence. We see it everywhere in the crumbling edifices that were once our proudest achievements. As each system becomes destabilised, the public that has become dependent on the provision of largess at the expense of our unborn great grandchildren demands that government do something to fix it. Each attempted fix just adds more complexity and more bureaucratic burden to an already overburdened society.

    This concept is not original to me. Joseph Tainter writes very eloquently of it in his book “The Collapse of Complex Societies” (1), which I think should be required reading for anyone with any policy-making authority. After describing the problem, Tainter also shows that sometimes a society will make a conscious decision to return to a simpler system, thereby breathing new life into their aging institutions.

    What we need is less government and less parasitic bureaucratic entities that feed off us at every turn. We need to slay the Canadian Sacred Cow of socialist monopoly health care. Blended systems that create healthy competition among and between the public and private sectors and individual service providers create evolutionary forces that make the system much more responsive to the needs of the patients, the people who work in the system and the tax payers. No overarching, micromanaging, all-encroaching government bureaucracy is required.

    By way of example, consider the vastly complex, beautifully efficient system of computers and satellites that form the Internet and its billions of access portals. No one government or business consciously created this. It evolved because the business and human environment favored its growth. Along the way it created huge wealth for millions of people while improving our lives in immeasurable ways. Of course there are dangers that it also brings, but that is just the reality of life in the real world. These dangers are best recognised and avoided on the individual level.

    If we want Medicine to similarly evolve, we must get out of its way. Stop the micromanagement. Stop the cancerous growth of government and professional bodies. Allow healthy competition.
    Taiwan has one of the highest standards of care in one of the best blended systems in the world. The State will pay for a basic suite of services, but this money is freely portable both within the public system and outside it to the private sector. If you want to save money, you go public. If you want enhanced service you go private. Because of the healthy business competition and the portability of the tax funded portion, the private sector is affordable by nearly everyone. Each patient that arrives at a clinic or hospital is seen as a source of revenue, unlike in Canada where each patient is viewed as a liability to the facility budget.
    In Taiwan they have a single bureaucracy employing only a few thousand bureaucrats for the 23 million people living there (2), unlike our 13 different provincial and territorial health care systems each with numerous redundant regional authorities all of which “serve” only 36 million. The service providers are much more autonomous than in Canada, and patients have the ability to self-refer to the specialities without going through a medical middle man. They also have a marvellous one patient/one record health information system that has to be seen to be believed. By including every medical encounter on a single cumulative record, duplications and omissions of service are minimised and data gathering for policy making is enhanced.
    Believe me, when my hip needs replacing, I will be going to Taiwan. For less than $10K USD I get 10 days in a luxury health spa, pre-op assessments, surgery, after care and physio therapy, all the while wining and dining at a 5-star level.
    So to sum up, burnout is just a symptom of systemic senescence. This senescence is a natural part of the lifecycle of large bureaucratic entities. If we want to do something substantive about it, we need less government interference and less parasitism by large professional bureaucracies and we need to allow the healthy competition between service providers to create an evolutionary environment that favors improved working conditions and better patient outcomes and satisfaction.

    (1) https://www.amazon.ca/Collapse-Complex-Societies-Joseph-Tainter/dp/052138673X
    (2) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3960712/

    1. First of all, I have to say that I am honored to have such thoughtful and intelligent readers already on my little blog. Second, thank you for taking the time to share your analysis. I couldn’t agree more that the system is also burned out. It is telling us all the time, “I don’t know how much longer I can do this,” and “I’m finding hard to care anymore.”

      I am very interested to learn more about this and potential solutions in particular. I will certainly look into your references. Thanks again, Dr. Ackerman.

  5. Well written per usual Matt, and some thoughtful comments that reflect effort and care – ironically things that are difficult to muster when feeling toasted.

    As I was drowning in paperwork today (charts, resident evals, department financials, etc) I had a recurring fantasy where I can move up north (further) and ‘just practice medicine’. Alas, in the current bureaucratic milieu that is simply a pipe dream. The only way through is out.

    Oh, and thx Dr. Ackerman – I’ve added Tainter to my burgeoning reading list.

    I’ve added Tainter to my reading list.

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